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_ MINNESOTA UNIQUE WELL <br /> WELL OR BRING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING CONSTRUCTION RECORD <br /> Hennepin Minnesota Statutes,Chapter 1031 [-826626 <br /> Township Name Township No. Range No. Section No. IFraction WELL BORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 117 23 03T +l � <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING ME <br /> Latitude Longitude ❑Cable Tool ❑Driven <br /> ❑Auger Rotary <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> 540 Willow DRS Orono 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes X11 <br /> Show exact location of well/boring in section gric with"X.' Sketch map of well/boring location. bentoriit@ From ft.To ft. <br /> Showing property lines, ggEE <br /> N rlCl roads,buildings,and direct. USE <br /> tic ❑Monitoring ❑Heating/Cooling <br /> i i______ 1 f� Rt711C6mmunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> ` Community PWS ❑Irrigation ❑Remedial <br /> NOV0 2 <br /> 4�for ❑Dewatering ❑ <br /> W E T CASING MATERIAL Drive Shoe? ❑Yes ,<No HOLE DIAM. <br /> Threaded <br /> MilWelded <br /> CITY OF 0 Nb °T °W <br /> 'h e � ° <br /> Diamete <br /> l <br /> CASING <br /> ,�- CASI G Weight Specifications Q <br /> I--1 Mile { k0?'p7 4 in.To 220 ft. Ibs./ft: v n.To 50 ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME n.To ft. lbs./ft. in.T730 ft. <br /> Nornp9p, Inc• in.To ft. lbs./ft. in.To ft. <br /> Property owner's mailing address if different than well location address indicated above. <br /> SCREEN OPEN HOLE <br /> Make ism To ft. <br /> 700 Fast lalC@ St n213 O�TiFrom ft. <br /> W f Y!' Type Stainless ess 4teal Diam. <br /> tdayzat8, t+ j 55391 SloUGauze .010 Length 41 4 49 <br /> Set between ft.and ft. FITTING M <br /> STATIC WATER LEVEL Measured from <br /> ftOBelow ❑Above land surface Date measured <br /> WELL OWNER'S NAME/COMPANY NAME PUIVIP1NG LEVEL(below land surface) f1 <br /> 210 ft.after 2 hrs.pumping 50g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �,�y,y yy�,,� <br /> �.� <br /> Pitless/adapter manufaci_6 Model <br /> ❑Casing protection 112 in.above grade <br /> ❑At-grade [:]Well House ❑Hand Pump /� <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> MaterialhPnt(N1�From 0 To--50_ft. 3 ❑Yds. Bags <br /> MaterialCUt_t ing From 50 To-220—ft. ❑Yds. ❑Bags <br /> HARDNESS OF Material From To ft. [-]Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To _Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> C18 /sand brown Toedium 0 31 99 feet 1A direction �l���_type <br /> clay/sand &ray nedium 31 Well disinfected upon completion? es E]No 4 <br /> "'ravel sand mix im 68 77 PUMP nf <br /> fine sand brown !;Oft77 150 E]Not installed Date installed 8—`"—27 <br /> gravel/clay brown Tedil= 1150 1r)3 Manufacturer's name G?�e. nfnr <br /> clay red um ��3 lq Model Number ; HPfl-5Volts230 <br /> clay ,,ray ium 184 204 Length of drop pipe 105 ft. Capacity g.p.m <br /> sand/gravel tan 1 ,iun 2. + 10 <br /> dine sand brown ( <jT'1 ?1'.J 21el Type Submersible E]L.S.Turbine [j Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> gravel/saner yellow nedium 219 1303 <br /> Does property have any not in use and not sealed well(s)? ❑Yes No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes>e No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,if needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Don Stodola Well DrillirkS Co, Inc. 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> 9-1£-17 <br /> Certified Representative Signature Certified Rep.No. Date <br /> LOCAL COPY �826626 Name of Driller Roti Stodole <br /> ID#52603 HE-01205-15(Rev.8/13) <br />